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ZONING PERMIT APPLICATION www.countyofdane.com i <br /> 1 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 2-CteW`Y Lk god" ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip D Deed Restriction; CSM <br /> 1 108a Ilt vAo(ic Variance(# ) <br /> HOME PHONE CELL PHONE 1E-MAIL ADDRESS <br /> 03 7CS:a d 712- 8771 3'4)140""& S,„fie-7r ❑ e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR.INFORMATION Ond includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS I CONTRACTOR ADDRESS of well/septic <br /> (City.State.Zip) 1(City,State.Zip) Setbacks <br /> PHONE i PHONE', ❑ $'te Plan.approval from <br /> applicable township. <br /> E-MAIL ADDRESS 1 E-MAIL ADDRESS l <br /> d Fpor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE TZONIN ACR E: Q'Elevation of property <br /> ❑ NUMBER C RO�p— I " &70- f\` 1 F- frontage drawn to scale. <br /> TOWNSHIP: SE N. r • +. <br /> B 6942 TO I • ) _ ❑ Driveway permits Y., S i <br /> ADD RESS: _ --- (state,county,town)L <br /> i �� 4.1.7.F.:74) I L. c oU 11- S <br /> w -- � �� 0 I ❑ Sanitary permits I\; �'�� <br /> C <br /> I <br /> SM: LOT SUBDIVISION BLOCK/LOT <br /> �� (public,private) (� 1 6�. a <br /> !— ill <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> P lE T DESC�IP71ON: r t <br /> (' , .- (.0 ( V&'F' .J 4.. ; b ■ •Wing District <br /> . ❑ is project is a new building or structure. aPermitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: j PERMIT NUMBER: Li Rural SS <br /> J SEWER ®SEPTIC 1 �J (new XlStln <br /> HEIGHT IN FEET 0 J NUMBER OF STORIES: (Not including basement) r'J <br /> a' ❑ Wetlandodplain/ <br /> horetand (attachment) <br /> AREA TO NEAREST SQUARE FOOT: i; <br /> (Outside dimensions inc uding unfinished area,attached garages and above grade decks or porches) <br /> ErosionControl permit I <br /> BASEMENT r r 1ST FLOOR: rr^ I n <br /> 864 �(�(`\.__ _ + TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, c f G ti u <br /> 80c 2ND FLOOR. '- 3RD FLOOR: NNNN j filling/access <br /> �� 901. ❑ Revi ocation Survey <br /> ESTIMATED CONSTRUCTION COST: --ii. --to --I. /� a available options. <br /> (Please round to nearest dollar) $ (j , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? :Yis Llo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the proOerty? s 0 No CI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ❑ o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes LYJ No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blanf none) <br /> 6. Is a location survey required? (see reverse) ❑Yes 0 f�o ❑Don't know <br /> 7. Is this to correct a violation? 1 ❑Yes 4 No <br /> -0` 3.5-'`�3 e______ APPLICATION MUST BE SIGNED <br /> \i, . <br /> 545-112(4108) c) <br /> /-/Lf (Continue on Back) —► ■ —► <br />